The Ultrasonic Bone Scalpel does not Outperform the High-Speed Drill: A Single Academic Experience

BACKGROUND

Spinal decompression and osteotomies are conventionally performed using high-speed drills (HSDs) and rongeurs. The ultrasonic bone scalpel (UBS) is a tissue-specific osteotome that preferentially cuts bone while sparing the surrounding soft tissues. There is ongoing investigation into its ability to optimize peri- and postoperative outcomes in spine surgery. The purpose of this study was to compare the intraoperative metrics and complications during a transition period from HSD to UBS.

METHODS

A single-institution, single-surgeon retrospective analysis was conducted of patients undergoing spine surgery from January 2020 to December 2021. Statistical analyses were performed to detect associations between the surgical technique and outcomes of interest. A P value < 0.05 was considered statistically significant.

RESULTS

A total of 193 patients met the inclusion criteria (HSD, n = 100; UBS, n = 93). Multivariate logistic regression revealed similar durotomy (P = 0.10), nerve injury (P = 0.20), and reoperation (P = 0.68) rates. Although the estimated blood loss (EBL) and length of stay were similar, the operative time was significantly longer with the UBS (192.81 vs. 204.72 minutes; P = 0.03). Each subsequent surgery using the UBS revealed a 3.1% decrease in the probability of nerve injury (P = 0.026) but had no significant effects on the operative time, EBL, or probability of durotomy or reoperation.

CONCLUSIONS

The UBS achieves outcomes on par with conventional tools, with a trend toward a lower incidence of neurologic injury. The expected reductions in EBL and durotomy were not realized in our cohort, perhaps because of a high proportion of revision surgeries, although these might be dependent on surgeon familiarity, among other operative factors. Future prospective studies are needed to validate our results and further refine the optimal application of this device in spine surgery.

Raney: a ubiquitous neurosurgical eponym

Prior to the 1937 invention of the Raney clip, surgeons relied on hemostatic sutures, pneumatic tourniquets, sequentially applied hemostatic forceps, and the administration of local vasoconstrictive agents to achieve scalp hemostasis. The Raney clip is now the quintessential tool for achieving scalp hemostasis in cranial neurosurgery; with nearly 13.8 million cranial neurosurgical cases per year globally, Raney clips are in high demand and their use is ubiquitous. What is less known, however, is the story of their invention and the related stories of those who bear the Raney name. This paper fills these gaps in neurosurgical history, using information obtained during an extensive series of contemporary interviews and correspondence with the Raney family.

Comparison of Perioperative and Long-term Outcomes Following PEEK and Autologous Cranioplasty: A Single Institution Experience and Review of the Literature

OBJECTIVE

Three-dimensionally (3D) printed polyether-ether-ketone (PEEK) implants are a relatively novel option for cranioplasty that have recently gained popularity. However, there is ongoing debate with respect to material efficacy and safety compared to autologous bone grafts. The purpose of this study was to offer our institution's experience and add to the growing body of literature.

METHODS

A single-institution retrospective analysis of patients undergoing cranioplasties between 2016 and 2021. Patients were divided into PEEK and autologous cranioplasty cohorts. Parameters of interest included patient demographics as well as perioperative (<3 months postoperative) and long-term outcomes (>3 months postoperative). A P value < 0.05 was considered statistically significant.

RESULTS

A total of 31 patients met inclusion criteria (PEEK: 15, Autologous: 16). Mean age of total cohort was 48.9 years (range 19-82 years). Modified Frailty Index (mFI) revealed greater rate of comorbidities among the Autologous group (P = 0.073), which was accounted for in statistical analyses. Multiple logistic regression model revealed significantly higher rate of surgical site infection in the Autologous cohort (31.3% vs. 0%, P = 0.011). Minor complications were similar between groups, while the Autologous group experienced significantly more major postoperative complications (50%) versus PEEK (13.3%) (P = 0.0291). Otherwise perioperative and long term complication profiles were similar between groups. Additionally, generalized linear model demonstrated both cohorts had similar mean hospital length of stay (LoS) (Autologous: 16.1 vs. PEEK: 10.7 days).

CONCLUSIONS

PEEK cranioplasty implants may offer more favorable perioperative complication profiles with similar long-term complication rates and hospital LoS compared to autologous bone implants. Future studies are warranted to confirm our findings in larger series, and further examine the utility of PEEK in cranioplasty.

Middle cerebellar peduncle approach for Nocardia brainstem abscess: illustrative case

BACKGROUND

Nocardia cyriacigeorgica represents a rare cause of cerebral abscesses. Rarer still are brainstem abscesses caused by this bacterial species in immunocompetent hosts. In fact, only one such brainstem abscess case has been described in the neurosurgical literature to our knowledge to date. Herein, a case of Nocardia cyriacigeorgica abscess in the pons is reported, as well as a description of its surgical evacuation via the transpetrosal fissure, middle cerebellar peduncle approach. The authors review the utility of this well-described approach in treating such lesions safely and effectively. Finally, the authors briefly review, compare, and contrast related cases to this one.

OBSERVATIONS

Augmented reality is additive to and useful for well-described safe entry corridors to the brainstem. Despite surgical success, patients may not regain previously lost neurological function.

LESSONS

The transpetrosal fissure, middle cerebellar peduncle approach is safe and effective in evacuating pontine abscesses. Augmented reality guidance supplements but does not replace thorough knowledge of operative anatomy for this complex procedure. A reasonable degree of suspicion for brainstem abscess is prudent even in immunocompetent hosts. A multidisciplinary team is critical to the successful treatment of central nervous system Nocardiosis.

Practical Use of Augmented Reality Modeling to Guide Revision Spine Surgery: An Illustrative Case of Hardware Failure and Overriding Spondyloptosis

BACKGROUND AND IMPORTANCE

Augmented reality (AR) is a novel technology with broadening applications to neurosurgery. In deformity spine surgery, it has been primarily directed to the more precise placement of pedicle screws. However, AR may also be used to generate high fidelity three-dimensional (3D) spine models for cases of advanced deformity with existing instrumentation. We present a case in which an AR-generated 3D model was used to facilitate and expedite the removal of embedded instrumentation and guide the reduction of an overriding spondyloptotic deformity.

CLINICAL PRESENTATION

A young adult with a remote history of a motor vehicle accident treated with long-segment posterior spinal stabilization presented with increasing back pain and difficulty sitting upright in a wheelchair. Imaging revealed pseudoarthrosis with multiple rod fractures resulting in an overriding spondyloptosis of T6 on T9. An AR-generated 3D model was useful in the intraoperative localization of rod breaks and other extensively embedded instrumentation. Real-time model thresholding expedited the safe explanation of the defunct system and correction of the spondyloptosis deformity.

CONCLUSION

An AR-generated 3D model proved instrumental in a revision case of hardware failure and high-grade spinal deformity.

Pediatric Traumatic Brain Injury: An Update on Preclinical Models, Clinical Biomarkers, and the Implications of Cerebrovascular Dysfunction

Traumatic brain injury (TBI) is a leading cause of pediatric morbidity and mortality. Recent studies suggest that children and adolescents have worse post-TBI outcomes and take longer to recover than adults. However, the pathophysiology and progression of TBI in the pediatric population are studied to a far lesser extent compared to the adult population. Common causes of TBI in children are falls, sports/recreation-related injuries, non-accidental trauma, and motor vehicle-related injuries. A fundamental understanding of TBI pathophysiology is crucial in preventing long-term brain injury sequelae. Animal models of TBI have played an essential role in addressing the knowledge gaps relating to pTBI pathophysiology. Moreover, a better understanding of clinical biomarkers is crucial to diagnose pTBI and accurately predict long-term outcomes. This review examines the current preclinical models of pTBI, the implications of pTBI on the brain’s vasculature, and clinical pTBI biomarkers. Finally, we conclude the review by speculating on the emerging role of the gut-brain axis in pTBI pathophysiology.

Cerebral vasculopathy and strokes in a child with COVID-19 antibodies: illustrative case

BACKGROUND

The ability of coronavirus disease 2019 (COVID-19) to cause neurological insults in afflicted adults is becoming increasingly understood by way of an ever-growing amount of international data. By contrast, the pandemic illness’s neurological effects in the pediatric population are both poorly understood and sparsely reported.

OBSERVATIONS

In this case, the authors reported their experience with a preschool-age child with hydrocephalus who suffered multiterritory strokes presumed secondary to immune-mediated cerebral vasculopathy as a result of asymptomatic COVID-19 infection.

LESSONS

Growing evidence indicates that COVID-19 can cause neurological sequelae such as encephalitis and strokes. In this case report, the authors discussed a case of cerebral vasculopathy and strokes in a pediatric patient who was positive for COVID-19.

Chemotherapy for the Management of Cerebral Metastases

Chemotherapy has played a minor role as adjuvant therapy in treatment of cerebral metastases from solid cancers. The blood-brain barrier and cerebral metastases' considerable machinery of self-preservation have been significant obstacles to delivery and efficacy of chemotherapy. However, several methods intended to surmount these challenges have arisen alongside advent of technology and with the development of targeted molecular therapies. Focused ultrasound and molecular Trojan horses represent two such novel means of increasing permeability of the blood-brain barrier to effector agents. Published data on efficacy of these targeted therapies remain mostly restricted to retrospective studies and phase II prospective clinical trials.

Trends and Cost-Analysis of Lower Extremity Nerve Injury Using the National Inpatient Sample

BACKGROUND

Peripheral nerve injuries (PNIs) of the lower extremities have been assessed in small cohort studies; however, the actual incidence, national trends, comorbidities, and cost of care in lower extremity PNI are not defined. Lack of sufficient data limits discussion on national policies, payors, and other aspects fundamental to the delivery of care in the US.

OBJECTIVE

To establish estimates of lower extremity PNIs incidence, associated diagnoses, and cost in the US using a comprehensive database with a minimum of a decade of data.

METHODS

The National Inpatient Sample was utilized to evaluate International Classification of Disease codes for specific lower extremity PNIs (9560-9568) between 2001 and 2013.

RESULTS

Lower extremity PNIs occurred with a mean incidence of 13.3 cases per million population annually, which declined minimally from 2001 to 2013. The mean ± SEM age was 41.6 ± 0.1 yr; 61.1% of patients were males. Most were admitted via the emergency department (56.0%). PNIs occurred to the sciatic (16.6%), femoral (10.7%), tibial (6.0%), peroneal (33.4%), multiple nerves (1.3%), and other (32.0%). Associated diagnoses included lower extremity fracture (13.4%), complications of care (11.2%), open wounds (10.3%), crush injury (9.7%), and other (7.2%). Associated procedures included tibial fixation (23.3%), closure of skin (20.1%), debridement of open fractures (15.4%), fixation of other bones (13.5%), and wound debridement (14.5%). The mean annual unadjusted compounded growth rate of charges was 8.8%. The mean ± SEM annual charge over the time period was $64 031.20 ± $421.10, which was associated with the number of procedure codes (β = 0.2), length of stay (β = 0.6), and year (β = 0.1) in a multivariable analysis (P = .0001).

CONCLUSION

These data describe associations in the treatment of lower extremity PNIs, which are important for considering national policies, costs, research and the delivery of care.

Application of Indocyanine Green During Arteriovenous Malformation Surgery: Evidence, Techniques, and Practical Pearls

Indocyanine green (ICG) is a fluorescent molecule that enables visualization of hemodynamic flow through blood vessels. The first description of its application to the resection of arteriovenous malformations (AVMs) did not occur until 2007. Since then, industry leaders have rapidly integrated this optical technology into the intraoperative microscope, and the use of ICG videoangiography (VA) has since become routine in AVM surgery among some academic centers. A number of case series have been published since the introduction of ICG VA to AVM neurosurgery. These early reports with small sample sizes were largely qualitative, assigning to the technology “usefulness” and “benefit” scores as perceived by the operators. This lack of objectivity prompted the development of FLOW 800 software, a proprietary technology of Carl Zeiss Meditec AG (Oberkochen, Germany) that can quantify relative fluorescence intensity under the microscope to generate color maps and intensity curves for ad hoc and post hoc analyses, respectively. However, subsequent case series have done little to quantify the effect of ICG VA on outcomes. The available literature predominately concludes that ICG VA, although intuitive to deploy and interpret, is limited by its dependence on direct illumination and visualization. The subcortical components of AVMs represent a natural challenge to ICG-based flow analysis, and the scope of ICG VA has therefore been limited to AVMs with a high proportion of superficial angioarchitecture. As a result, digital subtraction angiography has remained the gold standard for confirming AVM obliteration. In this review, we provide an overview of the existing literature on ICG VA in AVM resection surgery. In addition, we describe our own experiences with ICG VA and AVMs and offer the senior author's surgical pearls for optimizing the marriage of fluorescence flow technology and AVM resection surgery.

Awake craniotomy in glioma surgery: is it necessary?

INTRODUCTION

The awake craniotomy has evolved from its humble beginnings in ancient cultures to become one of the most eloquent modern neurosurgical procedures. The development of intraoperative mapping techniques like direct electrostimulation of the cortex and subcortical white matter have further argued for its place in the neurosurgeon's armamentarium. Yet the suitability of the awake craniotomy with intraoperative functional mapping (ACWM) to optimize oncofunctional balance after peri-eloquent glioma resection continues to be a topic of active investigation as new methods of intraoperative monitoring and some unfavorable outcome data question its necessity.

EVIDENCE ACQUISITION

The neurosurgery and anesthesiology literatures were scoured for English-language studies that analyzed or reviewed the ACWM or its components as applied to glioma surgery via the PubMed, ClinicalKey, and OvidMEDLINE® databases or via direct online searches of journal archives.

EVIDENCE SYNTHESIS

Information on background, conceptualization, standard techniques, and outcomes of the ACWM were provided and compared. We parceled the procedure into its components and qualitatively described positive and negative outcome data for each. Findings were presented in the context of each study without attempt at quantitative analysis or reconciliation of heterogeneity between studies. Certain illustrative studies were highlighted throughout the review. Overarching conclusions were drawn based on level of evidence, expert opinion, and predominate concordance of data across studies in the literature.

CONCLUSIONS

Most investigators and studies agree that the ACWM is the best currently available approach to optimize oncofunctional balance in this difficult-to-treat patient population. This qualitative review synthesizes the most currently available data on the topic to provide contemporaneous insight into how and why the ACWM has become a favorite operation of neurosurgeons worldwide for the resection of gliomas from eloquent brain.

Thoracic Paraspinal Castleman Disease in a Young Mexican-American Man with Postcoital Hematuria

BACKGROUND

Castleman disease (CD) is an uncommon disorder of deregulated lymphoproliferation with unicentric (UCD) and multicentric forms based on extent of nodal involvement. Gross resection with histopathologic analysis remains the gold standard for diagnosis of UCD and is curative in most cases. Symptomatic paraspinal UCD is a rare presentation with potentially dangerous complications, and its tendency to mimic more common spinal tumors presents a significant diagnostic challenge.

CASE PRESENTATION

A 25-year-old Hispanic man with no past medical history was evaluated for a known left-sided paraspinal mass that was incidentally discovered during an emergency department work-up for hematuria. Computed tomography on initial presentation revealed a 5.3 cm × 3.3 cm × 4.8 cm heterogeneously enhancing left paraspinal mass adjacent to the T11 vertebral body with tonguelike extension into the T11-T12 neural foramen. Although he remained neurologically intact throughout most of the diagnostic work-up, an inconclusive biopsy, worsening hematuria, and late-onset radiculopathy with severe back pain prompted surgical intervention. Microscopic histomorphology was consistent with CD. He continued to have intermittent hematuria and dysuria postoperatively, but repeat computed tomography at 7 months confirmed no recurrence of the mass.

CONCLUSIONS

Compared with previous reports, our case of postcoital hematuria and radiculopathy accompanying a paraspinal thoracic mass in a young Mexican-American man is a unique presentation. Awareness and early consideration of UCD in the work-up of a paraspinal mass may spare affected patients adverse and dangerous sequelae, such as spinal cord compression and excessive intraoperative hemorrhage.

Subarachnoid hemorrhage - Induced block of cerebrospinal fluid flow: Role of brain coagulation factor III (tissue factor)

Subarachnoid hemorrhage (SAH) in 95% of cases results in long-term disabilities due to brain damage, pathogenesis of which remains uncertain. Hindrance of cerebrospinal fluid (CSF) circulation along glymphatic pathways is a possible mechanism interrupting drainage of damaging substances from subarachnoid space and parenchyma. We explored changes in CSF circulation at different time following SAH and possible role of brain tissue factor (TF). Fluorescent solute and fluorescent microspheres injected into cisterna magna were used to track CSF flow in mice. SAH induced by perforation of circle of Willis interrupted CSF flow for up to 30 days. Block of CSF flow did not correlate with the size of hemorrhage. Following SAH, fibrin deposits were observed on the brain surface including areas without visible blood. Block of astroglia-associated TF by intracerebroventricular administration of specific antibodies increased size of hemorrhage, decreased fibrin deposition and facilitated spread of fluorophores in sham/naïve animals. We conclude that brain TF plays an important role in localization of hemorrhage and also regulates CSF flow under normal conditions. Targeting of the TF system will allow developing of new therapeutic approaches to the treatment of SAH and pathologies related to CSF flow such as hydrocephalus.

The effectiveness of CAHPS among women enrolling in Medicaid managed care

The large-scale transition of public health insurance programs to managed care has shifted much of the responsibility for selecting appropriate coverage to beneficiaries--a role for which many have had little preparation. This study evaluates the impact of a CAHPS (Consumer Assessment of Health Plans Study) health care report card in assisting newly enrolled Medicaid case heads in selecting a managed care plan. The major finding is that the CAHPS report card helped consumers make more informed decisions. Those who received the report cards found judging quality between plans easier, felt that they had significantly more information on which to make decisions, and recognized the importance of their decision more often than those receiving only standard enrollment packets.

Building pharmacoepidemiological capacity to monitor psychotropic drug use among children enrolled in Medicaid

This study's objective was to develop a methodology to apply pharmacoepidemiological research toward understanding and improving psychotropic drug use among children enrolled in Medicaid. Using Kansas Medicaid data for 1995-1996, we summarized drug claims, diagnoses, and demographics for children under 20 who received at least one psychotropic drug prescription over either year. The sequence of steps needed to assure a quality improvement role is discussed. Use of key personnel in less regulatory and more clinical data applications is critical. Illustrating this approach, we found disproportionate numbers of children receiving psychotropic drugs who were young boys and larger numbers of white children receiving psychotropic prescriptions relative to their Medicaid enrollment than either African-American or Hispanic children. Medicaid agencies can expand epidemiological capacity to understand service use among segments of the population they insure as part of an overall commitment to improving quality.